Could treating nightmares help prevent suicide?

Nightmares have been shown to increase the risk of suicidal behavior independent of other risk factors.

More than 40,000 deaths in the United States last year were due to suicide. This figure has increased by more than 20 percent over the past 10 years. For every suicide, there are 25 attempts. These statistics demonstrate one thing: that current measures are not working, and we need new methods to prevent people from attempting or considering suicide. But where to start? Michael Nadorff, a psychologist at Mississippi State University, argues that one treatable risk factor lurks in the shadows: nightmares.

Over the past five years, the psychologist’s research has shown that nightmares are associated with an increased risk of suicide—and that among suicidal individuals, treating the former may be an innovative approach to preventing the latter.

In scientific terms, suicide risk is measured by three elements: suicidal thoughts, suicidal behavior, and the likelihood a person believes they will die by suicide. In a 2011 study published in the journal Sleep, Nadorff and his colleagues assessed suicide risk in 583 students and then examined the association of the following symptoms with this risk: anxiety, depression, and nightmares. What they found was clear: the more severe the symptoms, the higher the risk of suicide. However, when they delved deeper into the influence of nightmares, they found that bad dreams predicted suicide risk more than other factors.

«What struck me at the time was not just nightmares associated with suicide, but the relationship that persisted even after we controlled for depression, anxiety, and post-traumatic stress disorder,» says Nadorff. «These are the most important risk factors in this area that people understand or can appreciate, but nightmares add something that others can’t.»

Nadorff conducted research and expanded on these findings in 2013, published in «Suicide and Life-Threatening Behavior,» where he showed the actual duration (in months or years) of a person’s nightmares. In other words, the longer a person is bothered by bad dreams, the higher the risk of suicide. In a 2014 article published in the Journal of Affective Disorders, Nadorff continued to look at how nightmares relate to the number of suicide attempts. He wanted to understand how various risk factors interact. If someone has already attempted suicide, what factors differentiate those who stop after one attempt from those who will try again? «Depression doesn’t exist, anxiety doesn’t exist, all these common risk factors don’t differentiate,» Nadorff notes. But nightmares increase the risk of a suicide attempt fourfold.

Other researchers have found similar results in other countries. The FINRISK National Surveys are a series of health surveys of the Finnish adult population, conducted every five years from 1972 to 2012, with a total of 76,071 respondents. Researchers from the University of Turku analyzed data from this large, population-based study and found that people with frequent nightmares were more than twice as likely to die by suicide, according to the Finnish National Death Register. At the University of Gothenburg in Sweden, a long-term study published in Psychiatry Research found that among people who had attempted suicide, those who suffered from nightmares were at greater risk of attempting suicide again within the following two years. Finally, a 2012 мета-реклам of 14 studies published in «The Journal of Clinical Psychiatry» suggests that those who suffer from nightmares are 2.61 times more likely to engage in suicidal behavior than people who do not have them.

WHY CAN NIGHTMARES TRIGGER SUICIDAL BEHAVIOR?

The first thing to consider is the situational context that leads to nightmares. Waking up from a bad dream is a deeply distressing and overwhelming experience. You’re overcome by the dream, the frightening images, lying alone in the dark, your heart pounding. Perhaps you dreamed of your ex-wife cheating on you. , the recent death of a loved one, or job loss. Now you’re trapped in this anxious state and can’t sleep, ruminating on emotional issues you’d probably prefer to avoid.

«You don’t have the same support you have during the day, so you have fewer barriers» to suicidal thoughts, explains Nadorff. In this light, a nightmare can push those on the brink of suicide over the edge.

In fact, a 2014 study published in «Sleep» and conducted at the University of Pennsylvania found evidence that suicide is more likely to occur at night, particularly between midnight and 6 a.m. For the study, they obtained estimated times for more than 35,000 suicides from the National Violent Death Reporting System. When accounting for the proportion of the population waking up every hour, the peak-hour suicide rate was 16 percent between 2 and 3 a.m., then dropped to 2 per day between 6 a.m. and midnight. In a 2016 article published in Sleep Medicine Reviews, the same researchers suggested that simply being awake at night increases the risk of suicide and concluded that targeted treatment for nightmares and insomnia should be included in suicide prevention programs.

Unfortunately, most healthcare providers do not ask patients about nightmares, and many patients are unlikely to report them. Incidentally, in a recent article published in the Journal of Clinical Sleep Medicine in 2015, Nadorff and colleagues also examined this issue. «I ask doctors every time: When you do a risk assessment, do you ever ask about nightmares? And no one ever does. No one ever.»

Fortunately, there are simple, quick, and effective treatments for nightmares, the most common of which is Imagery Rehearsal Therapy (IRT), which focuses on modifying the nightmare through waking visualization (altering the dream script). First, imagine the nightmare and write it down, modifying the ending to a more desirable one. This version of the «happy ending» of the nightmare is then visualized and rehearsed for 10-20 minutes throughout the day. IRT is well tolerated by patients and also significantly reduces the frequency and severity of nightmares over the long term, studies show.

One ​​of the benefits of nightmare therapy is that it makes it easier for patients to talk about bad dreams, focusing less on depression or suicidal thoughts. «People seem to love it,» says Nadorff, adding, «it’s one of my favorite treatments.» IRT also benefits suicidal-related arousal symptoms. «You treat the nightmares, and the depression goes away, the anxiety decreases, so all the major symptoms that bother us tend to improve.»

And here’s the best part! This simple therapy can be effective in treating nightmares after just 1-3 sessions. While longer-term work is needed to evaluate the approach, IRT nightmare treatment may be an ideal adjunctive treatment for suicidality, especially for those who have already attempted it.